holding anticoagulants for transforaminal ESIs

[ctts]

I still hold anticoagulants for all lumbar TF ESI. I understand some are not holding for TF ESI based on Endres paper? Especially if L4 or below? How about above L4? Just wondering if most of you are now not holding? I am admittedly slow to change, but considering that maybe I should.

---

Members don't see this ad.

 

[lobelsteve]

Hold for cervical, but I shouldn't.
Do not hold for anything lumbar TFESI or ILESI with 25G.

 

[RoloTomassi]

I do not hold for lumbar TFESI

 

[Ducttape]

I hold for all ILESI, and consider circumstances for TFESI.

 

[drrosenrosen]

Hold for cervical, but I shouldn't.
Do not hold for anything lumbar TFESI or ILESI with 25G.

Steve, can you review your 25ga epidural technique again? Thanks

 

[lobelsteve]

Steve, can you review your 25ga epidural technique again? Thanks

C7-T1 or lower.
Start over inferior lamina and numb it up on way down. Touch lamina. Pull back and direct superiorly in paramedian position. Advance under CLO until at football. Puff of omni before, then when through ligament. Perfect vertical line and go AP to look for any vasc uptake. Squirt the good stuff.

 

[drrosenrosen]

C7-T1 or lower.
Start over inferior lamina and numb it up on way down. Touch lamina. Pull back and direct superiorly in paramedian position. Advance under CLO until at football. Puff of omni before, then when through ligament. Perfect vertical line and go AP to look for any vasc uptake. Squirt the good stuff.

That's basically what I do with a larger needle. Do you do continuous pressure on the contrast as a LOR technique? Extension tubing or no?

 

[lobelsteve]

That's basically what I do with a larger needle. Do you do continuous pressure on the contrast as a LOR technique? Extension tubing or no?

There is no LOR I can feel. I always use extension tubing.

 

[MD87]

There is no LOR I can feel. I always use extension tubing.

What do you do for documented anaphylactic reaction to dye? Thanks.

 

[callmeanesthesia]

What do you do for documented anaphylactic reaction to dye? Thanks.

It’s not anaphylactic, it’s anaphylactoid, which makes a big difference. Usually their prior reaction was to a CT scan, where they got a rapid IV bolus of 20 mL+ of iodinated contrast. I talk to the patient, find out the history of the reaction, discuss that it is dose-dependent and I will be using only about 1/2 mL. I have them take PO Benadryl before the procedure, have an epi-pen ready just in case and monitor them for 15 minutes or so in the recovery area. If they aren’t comfortable with the plan I don’t do the injection.

 

[lobelsteve]

Little blue box. If true allergy: Steroid protocol day before and day of. Box contains: epipen, benadryl, decadron, H2 blocker

 

[nvrsumr]

I have heard of some some docs that just proceed without contrast. Heretics

 

[plasma.]

It’s not anaphylactic, it’s anaphylactoid, which makes a big difference. Usually their prior reaction was to a CT scan, where they got a rapid IV bolus of 20 mL+ of iodinated contrast. I talk to the patient, find out the history of the reaction, discuss that it is dose-dependent and I will be using only about 1/2 mL. I have them take PO Benadryl before the procedure, have an epi-pen ready just in case and monitor them for 15 minutes or so in the recovery area. If they aren’t comfortable with the plan I don’t do the injection.

Little blue box. If true allergy: Steroid protocol day before and day of. Box contains: epipen, benadryl, decadron, H2 blocker

These both seem like great approaches. Guys any references for these plans/discussions I can keep on hand in case I have to pull out the papers for someone in the future?

 

[RoloTomassi]

I have heard of some some docs that just proceed without contrast. Heretics

9/10 times they have"allergy" it's really not and I'll proceed with contrast. Very rarely when it really seems like it might be risky, I'll not use contrast if I get clean LOR and see air epidurogram.

 

[lobelsteve]

999/1000 times they have"allergy" it's really not and I'll proceed with contrast. Very rarely when it really seems like it might be risky, I'll not use contrast if I get clean LOR and see air epidurogram.

Fixed it for you.

 

[BobBarker]

I have never not used standard non ionic contrast. I just proceed as normal. I haven’t used gad since fellowship. Makes no sense to use it.

 

[deleted875186]

I have never not used standard non ionic contrast. I just proceed as normal. I haven’t used gad since fellowship. Makes no sense to use it.

Just read the update on all the adverse effects from gad, don’t know why anyone would even try to use gad.

 

[bedrock]

Just read the update on all the adverse effects from gad, don’t know why anyone would even try to use gad.

I have never not used standard non ionic contrast. I just proceed as normal. I haven’t used gad since fellowship. Makes no sense to use it.

Agree it is insane to use gad given the risks. It is a 99% likelihood that the patient doesn't have a true allergy to contrast. Just premedicate, or skip contrast depending on the situation, but using gad carries more risk that using contrast

 

[Ducttape]

i have "seen" true anaphylactic reaction to non-iodinated contrast. in honesty, i read the ICU admission notes and vent settings in said patient.

please do not be so cavalier.

standard prophylaxis is steroids prior and benadryl prior. that is a lot of steroids.


for ESI, my other technique is to grab a 3 ml syringe, fill it with gad, when noone is looking, squirt the gad in to the garbage can and put the syringe at the far end of the sterile field so noone accidentally grabs it.

the proceed as normal with LOR and CLO views. document that imaging was "appropriate for the medication utilized".

 

[lobelsteve]

i have "seen" true anaphylactic reaction to non-iodinated contrast. in honesty, i read the ICU admission notes and vent settings in said patient.

please do not be so cavalier.

standard prophylaxis is steroids prior and benadryl prior. that is a lot of steroids.


for ESI, my other technique is to grab a 3 ml syringe, fill it with gad, when noone is looking, squirt the gad in to the garbage can and put the syringe at the far end of the sterile field so noone accidentally grabs it.

the proceed as normal with LOR and CLO views. document that imaging was "appropriate for the medication utilized".

Your use of GAD is appropriate, and visualization is nearly the same...